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OPTUM PHARMACY 702, LLC
CHC26511-13 UPPER GREAT LAKES FAMILY HEALTH CENTER
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Covered Entity Details
Entity Name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Subdivision Name
Upper Great Lakes Family Health Mobil Unit I
Type
HRSA-Funded Health Center
340B ID
CHC26511-13
Entity Address
730 Lake Linden Ave
Laurium, MI 49913
Grant Number
H80CS26511
Participating Start Date
4/1/2024
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
3/11/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
2/22/2024
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